Project Summary/Abstract The safety and quality of care provided to nursing home residents are often sub-optimal. The key insight of the ?To Err is Human? report by the Institute of Medicine in 1999 is that most adverse safety events and errors in healthcare can be traced to system-level rather than individual staff-related issues. This has shifted patient safety improvement efforts from targeting individual staff to re-engineering the structures and processes of care in order to prevent future errors. This focus on ?culture of safety? also emphasizes supports for (rather than blame and punishment of) providers, continuous performance improvement, and evidence- based practices. While important efforts have been made to improve the patient safety culture in hospitals, relatively little attention has been paid to improving the safety culture in nursing homes. During the past several decades, federal and state policies have been implemented to address the longstanding resident care issues plaguing the nursing home industry. Key state policies ? including Medicaid nursing home reimbursement rates and methods (e.g. case-mix adjusted payment), state minimum quality mandates, and state minimum nurse staffing standards ? are shown to have improved nursing home quality and outcomes. Despite these positive findings, many safety and quality problems persist, suggesting the need for additional studies to better understand the strengths and weaknesses of these policies. This proposed study is designed to fill a significant knowledge gap by evaluating the impact of these broad state quality-of-care policies on the development of safety culture in nursing homes. The overall goal of the project is to identify those aspects of state regulatory & payment policies that may foster or prevent the development of nursing home patient safety culture. To achieve this goal, we will measure multiple domains of safety culture performance (e.g. management support for resident safety, non-punitive response to mistakes, and teamwork among healthcare providers) using the AHRQ developed and validated Nursing Home Survey on Patient Safety Culture (NHSPSC) instrument to be administered to top managers (administrators and directors of nursing) in a nationally-representative sample of nursing homes. We will also employ administrative and public use data for 2016, as well as collect primary data from state officials responsible for state nursing home quality regulations and state Medicaid programs. These data will be used to construct nursing home safety culture measures, and measures of state policies, facility covariates, and market conditions. Hypotheses will be tested using multivariable instrumental variable analyses and structural equation modeling performed at the nursing facility level.